137 - It’s Time for PBM Reform: How PBMs Have Hurt Pharmacies and Increased Drug Costs

HelixTalk - Rosalind Franklin University's College of Pharmacy Podcast

Sean P. Kane, PharmD, BCPS

Health & Fitness, Medications, Rosalindfranklin, Rfums, Pharmacy, Pharmd, Pharmacist, Medicine, Drugs

5 • 644 Ratings

🗓️ 5 October 2021

⏱️ 40 minutes

🔗️ Recording | iTunes | RSS

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Summary

In this episode, we reveal what goes on behind the scenes for drug pricing and pharmacy reimbursement with Dr. Benjamin Jolley. Our discussion covers important concepts like PBMs, DIR fees, MAC pricing, and even possible upcoming changes at the federal government.

Key Concepts

Prescription drug reimbursement is a major factor in the decline of independent pharmacies nationwide. Complex reimbursement models, fees, and drug pricing structures are frequently not well understood by both patients and many healthcare providers.
A pharmacy benefits manager (PBM) is a company hired by an insurance company to handle prescription drug coverage and reimbursement. Three PBMs control more than three-quarters of the entire US market and can often dictate the terms of a drug reimbursement contract with pharmacies.
PBMs determine how much they will pay for the cost of a medication using either a benchmark (such as the average wholesale price minus some percentage) or a list of the maximum allowable cost (MAC) maintained by the PBM. Pharmacies are required to accept the PBM’s reimbursement amount regardless of the cost the pharmacy paid to acquire the drug from a wholesaler.
DIR fees, clawbacks, and PBM rebate or discount agreements with manufacturers have resulted in lower reimbursements to pharmacies, higher drug prices for patients, and increased profits for PBMs.

Transcript

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0:00.0	Welcome to Helix Talk, an educational podcast for healthcare students and providers covering real-life clinical pearls, professional pharmacy topics, and drug therapy discussions.
0:11.0	This podcast is provided by pharmacists and faculty members at Rosal Franklin University College of Pharmacy.
0:17.0	This podcast contains general information for educational purposes only. This is not professional
0:22.4	advice and should not be used in lieu of obtaining advice from a qualified health care provider.
0:27.2	And now, on to the show.
0:31.1	Hey, this is Dr. Kane. Before we start today's episode, I just wanted to let you know that the audio
0:36.1	quality for Dr. Jolly was a little rough in the first few minutes, but about six or seven minutes into this,
0:41.9	everything clears up very nicely and he's very easy to hear. So if you hold on tight, I promise
0:46.3	you it's worth the wait because the content he delivers is absolutely amazing. So with that said,
0:51.0	on to the show. Welcome to Helix Talk episode 137.
0:56.5	I'm your co-host, Dr. Kane.
0:58.0	And I'm Dr. Patel.
0:59.4	And the title of today's episode is, it's time for PBM reform, how PBMs have hurt
1:04.6	pharmacies and increased drug costs.
1:07.5	And we actually have a special guest today to help us understand the complex world of
1:11.9	PBMs and pharmacy drug price reimbursements and things like that. And that's Dr. Benjamin Jolly.
1:17.0	Thank you so much for joining us today. Dr. Jolly, could you just kind of introduce yourself to the
1:21.2	audience before we get started? My name is Benjamin Jolly. I am a pharmacist. I work at my family's pharmacy, Jolly's pharmacy in Salt Lake City.
1:31.3	I am a third-generation pharmacist. My grandpa started our family business back in 1954.
1:38.3	My dad joined the business, then I joined the business, and I've done everything at the pharmacy from nuts to bolts,
1:47.7	from being a cashier to being a pharmacist. And also I do consulting work with pharmacies across the
1:58.3	country to help them understand this stuff.
	...

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